Effectiveness of an intensive care telehealth programme to improve process quality (ERIC): a multicentre stepped wedge cluster randomised controlled trial
Authors: Claudia D. Spies, Nicolas Paul, Christine Adrion, Elke Berger, Reinhard Busse, Ben Kraufmann, Ursula Marschall, Simone Rosseau, Claudia Denke, Henning Krampe, Enrico Dähnert, Ulrich Mansmann, Björn Weiss, Moritz F. Adam, Lucas Albers, Nicolai Andrees, Stefan Angermair, Felix Balzer, Sascha Bartsch, Sabine Becherer, Sebastian Boie, Jan-Peter Braun, Felix Busch, Askin Büyüközer, Jörg Caumanns, Jonas Cittadino, Eva M. Düllmann, Andreas Edel, Lisa Eymold, Cynthia S. Franke, Georg Fritz, Martina Gaßner, Alexander Geissler, Maximilian Goedecke, Susanne Görtzen, Julius Grunow, Edmund Hartung, Stefan Heidemann, Beata Hennig, Julian Herm, Anja Heymann, Moritz Höft, Jürgen Janke, Hans-Joachim Janssen, Marc Kastrup, Thomas Kibat, Sascha Kirsten, Robin Kleinwächter, Wilma Klink, Tobias Klöpper, Anna-C. Knauthe, Jens-Peter König, Thomas König, Max R. Krautz, Philipp Landgraf, Carola Loock, Ralf Lorenz, Alexandr Melnikov, Belinda Memmert, Mario Menk, Tobias Moormann, Lutz Nibbe, Stephan Niemetz, Michele Ocken, Michael Oppert, Mareen Pigorsch, Christian Pille, Ivo Pobering, Birgit Puhlmann, Melanie Rahmel, Stephan-Matthias Reyle-Hahn, Elena L. Ribet Buse, Susanne Röber, Steffen Rohde, Arne Röhrs, Max Rosenthal, Kerstin Roßberg, Kay Rumschüßel, Ulf Sander, Carsten Sanft, Maren Schmidt, Maximilian Schmidt, Sebastian Schmidt, Marc Schmittner, Julika Schön, Torsten Schröder, Franziska Staerck, Karin Steinecke, Sascha Tafelski, Sascha Treskatsch, Marlies Vogler, Steffen Weber-Carstens, Dirk Weiland, Renata Wojcik
Journal: Intensive Care Medicine (2023)

Supporting the provision of intensive care medicine through telehealth potentially improves process quality. This may improve patient recovery and long-term outcomes. We investigated the effectiveness of a multifaceted telemedical programme on the adherence to German quality indicators (QIs) in a regional network of intensive care units (ICUs) in Germany. We conducted an investigator-initiated, large-scale, open-label, stepped-wedge cluster randomised controlled trial enrolling adult ICU patients with an expected ICU stay of ≥ 24 h. Twelve ICU clusters in Berlin and Brandenburg were randomly assigned to three sequence groups to transition from control (standard care) to the intervention condition (telemedicine). The quality improvement intervention consisted of daily telemedical rounds guided by eight German acute ICU care QIs and expert consultations. Co-primary effectiveness outcomes were patient-specific daily adherence (fulfilled yes/no) to QIs, assessed by a central end point adjudication committee. Analyses used mixed-effects logistic modelling adjusted for time. This study is completed and registered with ClinicalTrials.gov (NCT03671447). Between September 4, 2018, and March 31, 2020, 1463 patients (414 treated on control, 1049 on intervention condition) were enrolled at ten clusters, resulting in 14,783 evaluated days. Two randomised clusters recruited no patients (one withdrew informed consent; one dropped out). The intervention, as implemented, significantly increased QI performance for "sedation, analgesia and delirium" (adjusted odds ratio (99.375% confidence interval [CI]) 5.328, 3.395–8.358), "ventilation" (OR 2.248, 1.198–4.217), "weaning from ventilation" (OR 9.049, 2.707–30.247), "infection management" (OR 4.397, 1.482–13.037), "enteral nutrition" (OR 1.579, 1.032–2.416), "patient and family communication" (OR 6.787, 3.976–11.589), and "early mobilisation" (OR 3.161, 2.160–4.624). No evidence for a difference in adherence to "daily multi-professional and interdisciplinary clinical visits" between both conditions was found (OR 1.606, 0.780–3.309). Temporal trends related and unrelated to the intervention were detected. 149 patients died during their index ICU stay (45 treated on control, 104 on intervention condition). A telemedical quality improvement program increased adherence to seven evidence-based German performance indicators in acute ICU care. These results need further confirmation in a broader setting of regional, non-academic community hospitals and other healthcare systems.